BT prep for CT pcp

Preparedness for Bioterrorism: A role for CT primary care providers: 

Preparedness for Bioterrorism: A role for CT primary care providers Amanda Durante, PhD Yale Center for Public Health Preparedness September 21, 2006

By the end of this session the learner should be able to:: 

By the end of this session the learner should be able to: List organisms that are considered Class A biological weapon agents. Describe basic epidemiologic and clinical characteristics of Class A agents. Access information on the prevention, diagnosis and treatment of Class A agents. Describe disease patterns that may suggest a bioterrorism outbreak. Describe CT-specific reporting requirements when a clinician suspects a disease that could cause a public health emergency. Describe ways CT primary care clinicians can get involved in disaster planning in CT.

Role of Primary Care Providers : 

Role of Primary Care Providers Be prepared to diagnose and treat BT diseases Keep alert to unusual disease patterns Use reportable disease system to alert public health officials of a potential problem Get involved in disaster planning process

Category A bioterrorism agents: 

Category A bioterrorism agents Anthrax (Bacillus anthracis) Smallpox (variola virus) Plague (Yersinia pestis) Tularemia (Francisella tularensis) Botulism (botulinum toxin) Viral Hemorrhagic Fever

CDC Category A Agents: 

CDC Category A Agents Easily disseminated and/or transmitted from person-to-person Cause high mortality and have the potential for major public health impact Might cause panic or social disruption Require special action for public health preparedness

Useful resource on BT agents for primary care providers: 

Useful resource on BT agents for primary care providers Weinstein RS, Alibek K. Biological and Chemical Terrorism: A Guide for Healthcare Providers and First Responders. Thieme, New York 2003 CDC BT pages - http://www.bt.cdc.gov/bioterrorism Epidemiology, diagnosis, treatment, prophylaxis, infection control

Anthrax: 

Anthrax

Anthrax clinical description: 

Anthrax clinical description An illness with acute onset characterized by several distinct clinical forms, including the following: Cutaneous: a skin lesion evolving during a period of 2-6 days from a papule, through a vesicular stage, to a depressed black eschar Inhalation: a brief prodrome resembling a viral respiratory illness, followed by development of hypoxia and dyspnea, with radiographic evidence of mediastinal widening Intestinal: severe abdominal distress followed by fever and signs of septicemia Oropharyngeal: mucosal lesion in the oral cavity or oropharynx, cervical adenopathy and edema, and fever

Etiologic agent : 

Etiologic agent Bacillus anthracis Encapsulated, aerobic, gram-positive, spore forming, rod-shaped bacterium Zoonotic disease in herbivors Spores resist adverse environmental conditions and disinfectant

Occurrence in the 21st Century: 

Occurrence in the 21st Century Naturally occurring cases – exposure to infected animals or spore contaminated animal products Intentional - Inhalational and cutaneous disease as are result of exposure to B. anthracis spores through U.S. mail

Modes of transmission: 

Modes of transmission Skin: direct skin contact with spores Respiratory tract: inhalation of aerosolized spores GI: consumption of undercooked meat or dairy from infected animals NO person-to-person transmission of inhalational or GI anthrax

Slide12: 

Anthrax: Cutaneous

Slide13: 

Anthrax: Cutaneous Day 4 Day 6 Day 10 Eschar formation Vesicle development Day 2

Slide14: 

Mediastinal widening JAMA 1999;281:1735–1745 Anthrax: Inhalational

Slide15: 

Mediastinal Widening and Pleural Effusion on Chest X-Ray in Inhalational Anthrax

Smallpox: 

Smallpox

Clinical Case Definition : 

Clinical Case Definition Classical presentation An illness with acute onset of fever ≥101º F followed by a rash characterized by firm, deep seated vesicles or pustules in the same stage of development without other apparent cause Clinically consistent cases presentations of smallpox that do not meet this classical clinical case definition a) hemorrhagic type, b) flat type, and c) variola sine eruptione.

Occurrence: 

Occurrence Ancient scourge – many millions killed Global eradication in 1980 Bioweapon potential Prior use in French-Indian War Produced by USSR It is believed that there are unaccounted for stocks

Etiologic agent: 

Etiologic agent Variola Virus No animal or environment reservoir or vectors

Modes of transmission: 

Modes of transmission Generally direct and fairly prolonged face-to-face contact Can be spread by direct contact with body fluids or contaminated objects Rarely spread in the air of enclosed settings such as buildings, buses, trains

Period of communicabililty: 

Period of communicabililty Sometimes contagious with onset of fever Most contagious during first 7 – 10 days of rash Contagious until last scab falls off

Slide22: 

Courtesy of World Health Organization Lesion Progression: Maculopapular Deep vesicles Pustules Scabs

Slide23: 

Courtesy of National Archives

Slide24: 

Courtesy of National Archives

Evaluating Patients for Smallpox CDC Algorithm: 

Evaluating Patients for Smallpox CDC Algorithm http://www.bt.cdc.gov/agent/smallpox/diagnosis/

Plague: 

Plague

Clinical description: 

Clinical description A disease characterized by fever and leukocytosis that presents in one or more of the following principal clinical forms: Regional lymphadenitis (bubonic plague) Septicemia without an evident bubo (septicemic plague) Plague pneumonia, resulting from hematogenous spread in bubonic or septicemic cases (secondary plague pneumonia ) or inhalation of infectious droplets (primary plague pneumonia) Pharyngitis and cervical lymphadenitis resulting from exposure to larger infectious droplets or ingestion of infected tissues (pharyngeal plague)

Etiologic agent - Yersinia Pestis: 

Etiologic agent - Yersinia Pestis Bacterium – gram negative rod Epizootic Normally circulates between small mammals via fleas without human involvement. During rodent plague epidemics, rodents die and fleas seek out other hosts including humans

Plague occurrence: 

Plague occurrence 3 Pandemics Justinian - 6th century Africa/Asia Black Death – 14th century Europe Worldwide – 19th/20th century Cases naturally occurring cases in the US Potential for use as bioweapon WWII Former USSR production

Transmission of Bubonic & Septicemic Plague : 

Transmission of Bubonic & Septicemic Plague Organism entry Contact of broken skin with contaminated materials Bite of infected flea Organism exit No spread from person-to-person under normal conditions

Transmission of pneumonic plague: 

Transmission of pneumonic plague Organism entry into lungs Breathing in Y. pestis Direct contact with a human or animal case of pneumonic plague Aerosolized for bioterrorism purposes Spread as a result of untreated bubonic or septicemic plague Organism exit from lungs Respiratory droplets

Bubo – ruptured inguinal lymph node: 

Bubo – ruptured inguinal lymph node

Femoral bubo: 

Femoral bubo

Axillary bubo: 

Axillary bubo

Slide36: 

Inglesby, et al. JAMA. 2000;283:2281-2290 Primary Pneumonic Plague

Botulism: 

Botulism

Occurrence: 

Occurrence U.S. incidence ~100 cases annually Use as bioweapon Japanese in WWII (Unit 731) Former US and USSR bioweapon programs Iraqi missiles and bombs armed with it Japanese cult in early 1990’s

Etiologic agent: 

Etiologic agent Neurotoxin produced by Clostridium botulinum Most lethal substance known

Clinical description – Foodborne botulism: 

Clinical description – Foodborne botulism Ingestion of toxin results in an illness of variable severity. Common symptoms are diplopia, blurred vision, and bulbar weakness. Symmetric paralysis may progress rapidly.

Clinical description – Infant botulism: 

Clinical description – Infant botulism Constipation, poor feeding, and “failure to thrive” that may be followed by progressive weakness, impaired respiration, and death

Clinical description – Wound botulism: 

Clinical description – Wound botulism An illness resulting from toxin produced by Clostridium botulinum that has infected a wound. Common symptoms are diplopia, blurred vision, and bulbar weakness. Symmetric paralysis may progress rapidly.

Other botulism: 

Other botulism Clinical description - See Foodborne Botulism Case classification Confirmed: a clinically compatible case that is laboratory confirmed in a patient aged greater than or equal to 1 year who has no history of ingestion of suspect food and has no wounds

Modes of transmission: 

Modes of transmission No person-to-person transmission Exposure types Foodborne - Ingestion of toxin Infant – Ingestion of C. botulinum Wound – Infection with C. botulinum Inhalation of aerosolized toxin As BT agent may be aerosolized or added to food or water

Tularemia: 

Tularemia

Clinical description: 

Clinical description An illness characterized by several distinct forms, including the following: Ulceroglandular:  cutaneous ulcer with regional lymphadenopathy Glandular:  regional lymphadenopathy with no ulcer Oculoglandular:  conjunctivitis with preauricular lymphadenopathy Oropharyngeal:  stomatitis or pharyngitis or tonsillitis and cervical lymphadenopathy Intestinal:  intestinal pain, vomiting, and diarrhea Pneumonic:  primary pleuropulmonary disease Typhoidal:  febrile illness without early localizing signs and symptoms

Etiologic agent – Fracisella tulerensis: 

Etiologic agent – Fracisella tulerensis Bacterium – gram negative coccobacillius Reservoirs small mammals Can be recovered from contaminated water, soil, straw, animal carcasses Highly infectious Inhalation or inoculation of 10 organisms can cause disease

Occurrence: 

Occurrence US - About 200 human cases reported per year Mostly in south-central and western states Bioweapon potential Less deadly but incapacitating Former US and USSR weaponized production WW II

Modes of transmission: 

Modes of transmission Contact with infected body fluids Environmental exposures Arthropod bites (ticks & deer flies) Handling infected animal tissue Contact or ingestion of contaminated food, water or soil Inhalation of aerosolized bacteria BT attack Lawn mowers

If aerosolized tularemia was released into in densely populated area: 

If aerosolized tularemia was released into in densely populated area Abrupt onset of a large number of acute, non-specific febrile illness (38º-40º C) beginning 3 – 5 days later Pleuropneumonitis developing in a significant proportion of cases during ensuing days and weeks. May also cause affect Eyes – ocular tularemia Broken skin – ulceroglandular or glandular disease Oropharyngeal disease with cervical lymphadeninitis

Clinical Features – Ulceroglandular form: 

Clinical Features – Ulceroglandular form Painful maculopapule, pustule, ulcer CDC/Emory University/Dr. Sellers. PHIL1344

Viral hemorrhagic fever: 

Viral hemorrhagic fever

VHF: 

VHF Group of illness caused by several distinct families of viruses 4 families Arenaviruses, filoviruses, bunyaviruses, flaviviruses

Clinical features - VHF : 

Clinical features - VHF Severe multisystem syndrome Overall vascular system damage Body’s ability to regulate itself is impaired Often accompanied by hemorrhagic (in itself not usually life threatening)

Ebola & Marburg Viruses - clinical course: 

Ebola & Marburg Viruses - clinical course Sudden onset of flu-like illness May progress to nausea, vomiting, diarrhea, abdominal pain, photophobia, maculopapular rash, DIC, internal and external hemorrhage, multiorgan failure with jaundice and renal insufficiency

Ebola and Marburg – Etiologic agents: 

Ebola and Marburg – Etiologic agents Flioviridae family viruses Among the most virulent viruses (25-90% case fatality depending on strain) Zoonotic Humans are incidental hosts

Slide57: 

Atlanta, Georgia: Electron Micrograph: Ebola virus causing African Hemorrhagic Fever. (Courtesy of the National Archives, 82-424)

Marburg & Ebola –Occurrence: 

Marburg & Ebola – Occurrence Naturally occurring sporadic outbreaks in Africa Cases have occurred in West as a result of exposure to animal reservoirs BT potential Russian biowarfare program Iraq is believe to have tried

Ebola and Marburg - transmission: 

Ebola and Marburg - transmission Direct contact with infected tissue and body fluids or contaminated objects Probably aerosol inhalation

Role of Clinicians: 

Role of Clinicians Be prepared to diagnose and treat BT diseases Keep alert to unusual disease patterns Use reportable disease system to alert public health officials of a potential problem Get involved in disaster planning process

Clusters of patients with the same disease or syndrome: 

Clusters of patients with the same disease or syndrome Especially when: there is more cases than would be expected cases are geographically or temporally clustered the illness is unexplained there are multiple atypical presentations of the disease the mortality or morbidity is higher than expected

Even a single case may be a signal: 

Even a single case may be a signal Caused by an uncommon agent Unusual for region, age group or season Fulminant disease in otherwise healthy patient Atypical presentation

Other clues: 

Other clues Similar genetic type of agent from distinct sources Unusual, atypical, genetically engineered, or antiquated strain Atypical aerosol, food, or water transmission Concurrent animal disease

Role of Clinicians: 

Role of Clinicians Be prepared to diagnose and treat BT diseases Keep alert to unusual disease patterns Use CT reportable disease system to alert public health officials of a potential problem Get involved in disaster planning

CT Reportable Disease surveillance: 

CT Reportable Disease surveillance Clinicians required to report any of a list of diseases upon recognition or strong suspicion List available at http://www.dph.state.ct.us/BCH/infectiousdise/pdf/Vol26No1_FNLCLR.pdf

Category 1 diseases/conditions - 2006: 

Category 1 diseases/conditions - 2006 Reportable immediately by telephone to local Director of Health and CT DPH Epidemiology Program (860 507 7722)

Reporting provides access to : 

Reporting provides access to Local and CT Department of Health resources Epidemiologic investigation Clinical consultation Laboratory testing Risk communication Link to other relevant agencies

Surveillance case definitions: 

Surveillance case definitions US Case Definitions for Infectious Conditions Under Public Health Surveillance http://www.cdc.gov/epo/dphsi/casedef/index.htm

Role of Clinicians: 

Role of Clinicians Be prepared to diagnose and treat BT diseases Keep alert to unusual disease patterns Use CT reportable disease system to alert public health officials of potential problem Get involved in disaster planning process

National Incident Management System: 

National Incident Management System Standard approach to incident management and response developed by the DHS in March 2004 uniform set of procedure that all emergency responders use to conduct response operations Participate in opportunities for training In-house TRAINConnecticut - https://ct.train.org/DesktopShell.aspx

Disaster planning: 

Disaster planning Insure that Charter Oak Health Center is involved in the on-going disaster planning process Attend Capitol Region Emergency Planning Committee meetings

Acknowledgements: 

Acknowledgements Centers for Disease Control and Prevention Bioterrorism: Basics for Primary Care Practitioners. Center for Biosecurity. University of Saint Louis.